Heart Failure 101 The Basic Principles of Diagnosis & Management Bill Tran, MD Non Invasive Cardiologist February 24, 2018 What the eye does not see and the mind does not know, does not exist. DH Lawrence Learning Objectives Societal Impact of Heart Failure Pathophysiology Clinical Diagnosis Principles of Management Improving Heart Failure in our Community 1
What is Heart Failure? Inability of the heart to meet the oxygen demands of the body due to structural or functional abnormalities Heart failure with reduced ejection fraction (HFrEF) EF 40 % Heart failure with preserved ejection fraction (HFpEF) EF > 40 % Societal Impact of Heart Failure Affects 26 million people worldwide In 2012, 5.7 million people had a diagnosis of heart failure in the US (2.2% of population) $30.7 billion health care dollars spent Mean cost per HF related hospitalization ~ $14,632 Median length of stay: 5 days HF Readmission rate: 22.3% In 2030, it is projected that 8 million people in the US will suffer from heart failure Projected to cost $160 billion annually Readmissions, multiple drug therapy, devices, & heart transplant Associated with high morbidity and mortality In 2011, 1 in 9 death certificates cited HF as cause of death More the 50% of patients with HF die within 5 years of diagnosis Kilgore, M et al. Risk Management and Healthcare Policy. 2017:10 63 70. Farmakis D et al. Continuing Cardiology Education. 2017; 3(3), doi: 10.1002/cce2.50 How about HF Hospitalization Rates in your county? HF Hospitalization Rate per 1,000 Medicare Benificiaries, 65+, All Race, All Gender, 2012 2014 https://nccd.cdc.gov/dhdspatlas/default.aspx?state=mn 2
Pathophysiology of HFrEF: Neurohormonal Activation Beta Blockers Ivabradine ACE inhibitors ARB ARNI Nitrates Hydralazine Mineralocorticoid antagonists Diuretics Filippatos TD et al. World J Cardiol 2013; 5(9): 317 328 Clinical Diagnosis Diagnostic Tests Baseline Vitals Hypoxia, Blood pressure, Tachycardia, Tachypnea ECG Arrhythmias, MI, LBBB, AV Block Echocardiogram CXR LV Function, Structural Abnormalities Pulmonary congestion, Cardiomegaly, other causes of SOB (PTX, PNA etc) Labs BNP or NT ProBNP CBC Basic Metabolic Panel Thyroid Function LFTs Troponin Brown, P et a. Continuing Cardiology Education, 2017; 3(1), doi: 10.1002/cce2.50 Principles of Management for HFrEF Loop Diuretics Lasix Bumex Torsemide Thiazide Diuretics Metolazone Chlorthiazide Mechanical Support Diurese BB, ACEi/ARB/MA Vasodilate vs. Inotrope Diurese Cardiogenic Shock Cardiogenic Shock Vasodilators Nitroprusside Nitroglycerin Inotropes Milrinone Dobutamine Yancy, C et al. J Am Coll Cardiol 2013;62:1495 539. 3
JACC Aug 2017, 70 (6) 776 803 Appropriate Therapy Does Save Lives! On Triple Therapy (BB, ACEi/ARB/AA) Journal of the American College of Cardiology Oct 2003, 42 (7) 1234 1237 How do these new medications work? ARNI (Sacubitril Valsartan: ENTRESTO) Indications & Titration EF 35%, NYHA II III on GDMT for 3 months Can tolerate ACEi/ARB Need to stop ACEi 36 hours before starting Start 49/51 mg BID or 24/26 mg BID Max dose: 97/103 mg BID Up titrate after 2 weeks if no adverse effects (similar to ACEi or ARB) 4
How do these new medications work? (Ivabradine : CORLANOR) Indications & Titration EF 35%, NYHA II III, on GDMT for 3 months with BB at maximum dose, in sinus rhythm with HR 70 bpm at rest Start at 5 mg BID or 2.5 mg BID if history symptomatic bradycardia or conduction defects Max dose 7.5 mg BID Increase by 2.5 mg every 2 weeks to max dose or goal HR 50 60 bpm HCN: hyperpolarizaton activated cyclic nucleotide gated channel blocker Tse S, Mazzola N. Pharmacy and Therapeutics. 2015;40(12):810 814. Device Therapy for HFrEF Primary Prevention ICD All patients need to be on GDMT with beta blocker and ACEi/ARB for at least 3 months Life expectancy > 1 year ICD Criteria ICM, EF 35%, NYHA II III, 40 d post MI, or 90 d post revascularization ICM, EF 30%, NYHA I, 40 d post MI, or 90 d post revascularization NICM, EF 35%, NYHA II III CRT D Criteria EF 35%, NYHA III IV, QRS 120 ms Ideal patient w/ LBBB, QRS 150 ms Journal of the American College of Cardiology Aug 2017, 70 (6) 776 803 5
What about HFpEF? Not much data of effective medical therapies for HFpEF (EF > 40%). Treatment focused on treatment of medical comorbidities and symptoms. JACC Aug 2017, 70 (6) 776 803 Implantable Hemodynamic Monitoring: CardioMems Using Wireless Technology to measure PA pressure to combat HF Readmissions CHAMPION Trial: randomized single blind trial Device is implanted in the left PA and provides immediate assessment of PA systolic, diastolic and mean PA pressure that can monitored over time FDA approved in 2014 Indicated for HFpEF & HFrEF patients with NYHA III w/ 1 HF hospital admission in last 12 months Diuretic responsive & tolerate warfarin or Plavix/ASA for 1 month Enrolled from 64 centers in USA, N=550 (Rx: 270) Primary Endpoint: HF related admissions at six months Treatment group had 37% reduction in HF related admission compared to control group Abraham, W et al. Lancet. 2011 Feb 19;377(9766):658 66. Improving Heart Failure in Our Community Heart Failure Team of Nurse Practitioners, Pharmacists and RNs to help with HF education and have close follow up after hospitalization Tele health home monitoring systems to monitor weights to assist with early contact and intervention Working on improving online educational resources for patients Development of regional heart failure order sets to help diagnose and manage HF Any thoughts and feedback on what we can do to help you? Any suggestions? 6
Conclusions Heart Failure is a growing epidemic that has both high morbidity and mortality, as well as associated with heavy economic to our health care system Neurohormonal activation of the Renin Angiotensin Aldosterone System is the underlying mechanism for the pathophysiology of HF There are effective management strategies for HFreF, but not so much for HFpEF CardioMems is a new wireless technology that can help reduce HF readmissions We need to work together as a community to help earlier diagnose and treat HF as well as prevent HF readmissions A diagnosis is easy as long as you think about it. Soma Weiss Questions? Thoughts? Suggestions? Thank you for your attention! 7